A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Activity intolerance.

Fluid volume excess.

Ineffective airway clearance.

Altered nutrition; less than body requirements.

Answer and Explanation

The Correct Answer is C

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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Correct Answer is D

Explanation

Choice A reason: Assessing communication ability is important but secondary to establishing a structured routine to address the client's immediate needs.

Choice B reason: Arranging a meeting with the family can provide support but is not the first priority in managing the client's depressive symptoms.

Choice C reason: Administering antidepressant medication is essential but must be part of an overall structured plan.

Choice D reason: Establishing a structured routine helps provide stability, encourages participation in daily activities, and addresses the client's refusal to eat and bathe.

A. Report the client's jaw pain to the healthcare provider. B. Advise the client to gargle with warm salt water twice daily. C. Determine how the client is administering the medication. D. Confirm that this is a common symptom of osteoporosis.

Correct Answer is A

Explanation

Choice A reason: Reporting the client's jaw pain to the healthcare provider is essential because jaw pain can be a symptom of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonate therapy.

Choice B reason: Advising the client to gargle with warm salt water may provide temporary relief, but it does not address the underlying issue of potential osteonecrosis.

Choice C reason: Determining how the client is administering the medication is important for proper use but does not address the immediate concern of jaw pain.

Choice D reason: Confirming that this is a common symptom of osteoporosis is incorrect. Jaw pain is not a common symptom of osteoporosis and requires further evaluation.

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A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Correct Answer is D

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

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